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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ,(� �� (For Non-Transferable, Revocable, and Suapendable) <br /> wL ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> r <br /> Business Name (PBA) Addres <br /> OF <br /> a 0wnerle-0 `21Y07 e-?f#'47f _ Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. _ QQ <br /> a Applicants Name (Print) f `- � Title e Date 10 <br /> Please check Applicable Category (1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) _— <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical-Toilets Stored <br /> �,- 3 PERCOLATION TEST <br /> Ii.G1-er R.C.E. Name _ I? r^ "�/ R e1•R.C,E. No. <br /> Test Location 6J �' � `'�� �• Test Date/Time <br /> 4. ❑ SANITATION PERMIT — <br /> Job Address/Location _ <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 _. <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cieping LOcation(s) . <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified 4L - 3 <br /> Plant Location <br /> Plant Capacity No. Units Served _ <br /> 7. ❑ LAUNDRY For July 1, - June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft-, ❑ More Than 1,000 Sq. Ft <br /> C1 DRY CLEANING, Chemicals Used/Amount/Mo. - -_ 2- <br /> I hereby certify that I have rspared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE X -� �9 Title y `' ` f Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE .�{ REMITTED AMOUNT <br /> FEE i L p ✓ �~ .... <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OT EE/R/ <br /> •� Kms+1/4 r <br /> Received by a Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201-1- <br />